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Duarte J, Björkstrand FK, McCracken L, Perrin S. The contribution of psychological flexibility to functioning in people living with cancer-related pain. Eur J Pain 2023; 27:413-423. [PMID: 36516364 DOI: 10.1002/ejp.2067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 11/16/2022] [Accepted: 12/11/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Studies of individuals with non-cancer-related chronic pain find that higher levels of psychological flexibility (PF) are associated with less distress, better functioning, and a better response to treatment. People diagnosed with cancer are at a significantly increased risk of developing chronic cancer-related pain, the presence of which is associated with poorer health outcomes. Little is known about whether PF is applicable to cancer pain. The current study investigates the relationship between chronic cancer-related pain, distress and functioning, and three theoretical processes proposed by the PF model: pain acceptance, present-moment focus, and committed action. METHODS Adults (n = 246) with a cancer diagnosis (current or previous), and living in Sweden, completed an online survey involving standardized measures of cancer-related pain (intensity and impairment), depression, fatigue, PF and social stigma. RESULTS Moderate to strong correlations were found between PF and all variables. In regression analyses, PF, and particularly pain acceptance, accounted for a large and significant proportion of the observed variance in depression, pain-related and overall functioning, after controlling for cancer status, pain intensity and social stigma. CONCLUSION Consistent with studies of non-cancer-related pain, higher levels of PF were strongly associated with lower levels of distress and better functioning in individuals with cancer-related pain. Further studies are needed to further explore these relationships and to determine whether psychosocial treatments targeting PF may be of benefit to people with chronic cancer-related pain. SIGNIFICANCE This study explores the relationship between cancer-related pain (intensity and impairment), depression, fatigue, overall functioning, social stigma and PF. The findings suggest that higher levels of PF are associated with lower levels of distress and improved functioning in chronic cancer-related pain, after controlling for cancer status (current, in remission), pain intensity and social stigma.
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Affiliation(s)
- Joana Duarte
- Department of Psychology, Lund University, Lund, Sweden
| | | | - Lance McCracken
- Department of Psychology, Uppsala University, Uppsala, Sweden
| | - Sean Perrin
- Department of Psychology, Lund University, Lund, Sweden
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Tabrizi FF, Larsson AB, Grönvall H, Söderstrand L, Hallén E, Champoux-Larsson MF, Lundgren T, Sundström F, Lavefjord A, Buhrman M, Sundin Ö, McCracken L, Åhs F, Jansson B. Psychometric evaluation of the Swedish Multidimensional Psychological Flexibility Inventory (MPFI). Cogn Behav Ther 2022:1-22. [PMID: 36562150 DOI: 10.1080/16506073.2022.2153077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Psychiatric disorders are common, and reliable measures are crucial for research and clinical practice. A cross-diagnostic construct that can be used to index treatment outcomes as well as prevalence of psychological ill health is psychological flexibility. The aim of this study was to validate a Swedish version of the Multidimensional Psychological Flexibility Inventory (MPFI). The MPFI has 12 subscales, six of which measure flexibility, and six that measure inflexibility. Using confirmatory factor analysis in a community sample of 670 participants, we found that a model with two higher order factors had satisfactory fit (CFI = .933) and a 12-factor model had the best fit to the data (CFI = .955). All 12 subscales showed adequate reliability (CRs = .803-.933) and the factor structure was similar across age groups and gender. Findings suggest that the Swedish version of the MPFI is a reliable instrument that can be used to index psychological flexibility. Potential areas for improvement of the instrument are discussed.
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Affiliation(s)
- Fara F Tabrizi
- Department of Psychology & Social Work, Mittuniversitetet, Östersund, Sweden
| | - Andreas B Larsson
- Department of Psychology & Social Work, Mittuniversitetet, Östersund, Sweden
| | - Hampus Grönvall
- Department of Psychology & Social Work, Mittuniversitetet, Östersund, Sweden
| | - Lux Söderstrand
- Department of Psychology & Social Work, Mittuniversitetet, Östersund, Sweden
| | - Ellen Hallén
- Department of Psychology & Social Work, Mittuniversitetet, Östersund, Sweden
| | | | - Tobias Lundgren
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, & Stockholm Health Care Services, Stockholm, Sweden
| | - Felicia Sundström
- Department of Psychology, Clinical Psychology, Uppsala Universitet, Uppsala, Sweden
| | - Amani Lavefjord
- Department of Psychology, Clinical Psychology, Uppsala Universitet, Uppsala, Sweden
| | - Monica Buhrman
- Department of Psychology, Clinical Psychology, Uppsala Universitet, Uppsala, Sweden
| | - Örjan Sundin
- Department of Psychology & Social Work, Mittuniversitetet, Östersund, Sweden
| | - Lance McCracken
- Department of Psychology, Clinical Psychology, Uppsala Universitet, Uppsala, Sweden
| | - Fredrik Åhs
- Department of Psychology & Social Work, Mittuniversitetet, Östersund, Sweden
| | - Billy Jansson
- Department of Psychology & Social Work, Mittuniversitetet, Östersund, Sweden
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Casey MB, Smart KM, Segurado R, Hearty C, Gopal H, Lowry D, Flanagan D, McCracken L, Doody C. Exercise combined with Acceptance and Commitment Therapy compared with a standalone supervised exercise programme for adults with chronic pain: a randomised controlled trial. Pain 2022; 163:1158-1171. [PMID: 34913883 DOI: 10.1097/j.pain.0000000000002487] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 09/10/2021] [Indexed: 10/20/2022]
Abstract
ABSTRACT A prospective, 2-armed, parallel group randomised controlled trial (RCT) was conducted to compare the effectiveness of Acceptance and Commitment Therapy (ACT) combined with a supervised exercise programme with a supervised exercise programme alone for adults with chronic pain. One hundred seventy-five participants were individually randomised to receive either the combined Exercise and ACT (ExACT) intervention or supervised exercise alone. Those allocated to the ExACT group attended 8 weekly sessions with a psychologist based on the ACT approach, in addition to supervised exercise classes led by a physiotherapist. The control group attended weekly supervised exercise classes but did not take part in an ACT programme. Both groups were followed up postintervention and again after 12 weeks. The primary outcome was pain interference at 12-week follow-up. Estimates of treatment effects at follow-up were based on intention-to-treat analyses, implemented using a linear mixed-effects model. The findings of this RCT showed no difference in the effectiveness of ExACT, compared with a supervised exercise programme alone for the primary outcome pain interference at 12-week follow-up (mean difference -0.18, 95% confidence interval -0.84 to 0.48, P = 0.59, d = 0.11). ExACT group participants reported superior outcomes for pain self-efficacy, pain catastrophising, and committed action, compared with the control group, but there were no differences between the groups for other secondary outcomes or treatment process measures. Higher levels of treatment satisfaction and global impression of change were reported by ExACT group participants. Exercise combined with Acceptance and Commitment Therapy was not superior to a standalone supervised exercise programme for reducing pain interference in adults with chronic pain.
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Affiliation(s)
- Máire-Bríd Casey
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, Belfield, Dublin, Ireland
| | - Keith M Smart
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, Belfield, Dublin, Ireland
| | - Ricardo Segurado
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, Belfield, Dublin, Ireland
| | - Conor Hearty
- Department of Pain Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Hari Gopal
- Department of Pain Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Damien Lowry
- Department of Psychology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Dearbhail Flanagan
- Physiotherapy Department, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Lance McCracken
- Department of Psychology, Uppsala University, Uppsala, Sweden
| | - Catherine Doody
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, Belfield, Dublin, Ireland
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Gilpin H, Ratanachatchuchai S, Novelli D, McCracken L, Scott W. Examining the association between group context effects and individual outcomes in an interdisciplinary group-based treatment for chronic pain based on Acceptance and Commitment Therapy. Br J Pain 2022; 16:420-432. [PMID: 36032341 PMCID: PMC9411762 DOI: 10.1177/20494637211073012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Although cognitive-behavioural treatments for chronic pain are delivered in groups, there is little research investigating group effects in these treatments. Purpose: The aim of this study was to investigate associations between group composition variables at the start of treatment and individual outcomes following intensive interdisciplinary treatment for pain based on Acceptance and Commitment Therapy. Methods: This was a secondary analysis of routinely collected observational data. Five-hundred and sixteen patients completed a standard set of demographic, pain-related, and psychosocial measures at pre- and post-treatment. Intracluster correlations (ICCs) were computed to examine the clustering of outcomes within groups and multilevel models explored the association between group composition variables and individual level outcomes. Results: The ICCs for pain intensity (0.11) and interference (0.09) suggested that multilevel models were warranted for these outcomes, while a multilevel model for post-treatment depression (ICC=0.04) was not warranted. Group percentage of participants receiving disability 8 benefits and group mean pain intensity at pre-treatment were significantly positively associated with individual level pain intensity at post-treatment, controlling for pre-treatment individual level pain intensity. Group mean pain intensity at pre-treatment was the only group variable that significantly predicted post-treatment pain interference at the individual level. Psychosocial group composition variables were not significantly associated with individual level outcomes. Conclusions: Given the limited predictive utility of group composition variables in the current study, future research should undertake direct assessment of group level therapeutic and counter-therapeutic processes to advance understanding of who benefits from group treatments for pain and how. As the variance in outcomes accounted for by group clustering was relatively small and significant within groups variance remained, research is also needed to further understand individual level factors that influence cognitive-behavioural treatment outcomes for pain.
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Affiliation(s)
| | | | | | | | - Whitney Scott
- Health Psychology Section, Institute of Psychiatry, Psychology, and NeuroscienceKing's College London
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Bridgewater S, Lomax J, Abbott B, Adams J, Berry A, Creanor S, Ewings P, Hewlett S, McCracken L, Ndosi M, Thorn J, Urban M, Dures E. O26 Testing an intervention to reduce fatigue impact in inflammatory arthritis: design and outcomes of a single-arm feasibility study. Rheumatology (Oxford) 2021. [DOI: 10.1093/rheumatology/keab246.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background/Aims
Patients with inflammatory arthritis report that fatigue can be a challenging symptom to manage, with little support available. In response, we developed a brief one-to-one cognitive-behavioural manualised intervention, delivered by rheumatology health professionals (RHPs), to help patients manage their fatigue.
Methods
We designed a single-arm feasibility study called FREE-IA (Fatigue - Reducing its Effects through individualised support Episodes in Inflammatory Arthritis). Patients were eligible if they were ≥18 years, had a clinician confirmed diagnosis of inflammatory arthritis, scored ≥6/10 on the BRAF NRS Fatigue Impact with fatigue that they considered recurrent, frequent, and/or persistent, and were not accessing support for their fatigue.
Following training, RHPs delivered 2-4 one-to-one sessions to participants. The initial two core sessions were delivered face-to-face in clinic; participants then had the option of up to two further sessions, either in clinic, by telephone or online. We proposed delivering sessions 1 and 2 within two weeks of each other, and sessions 3 and 4 in the following two weeks. Baseline data were collected before the first session (T0), and outcomes at six weeks (T1) and six months (T2). The primary outcome was fatigue impact (BRAF NRS Fatigue Effect), collected by telephone. Secondary outcomes included fatigue severity, fatigue coping, multi-dimensional impact of fatigue, disease impact and disability and measures of therapeutic mechanism (self-efficacy, and perceived confidence and autonomy to manage health). These outcomes were collected by post.
This study allowed us to test the feasibility and acceptability of RHP training, study design and materials, intervention delivery and outcome collection, ahead of a possible RCT to determine intervention effectiveness.
Results
Eight RHPs at five hospitals delivered 113 sessions to 46 participants. Four sessions were delivered by phone and none online. Session 2 was only delivered within the two-week time frame for 37% of participants attending both core sessions. Out of a potential 138 primary and secondary outcome responses at T0, T1 and T2, there were 13 missing primary outcome responses and 27 missing secondary outcome responses. Results indicated improvements in all measures except disability at either T1 or T2, or both, with confidence intervals supporting an interpretation of improvement.
Conclusion
We were able to design and deliver FREE-IA training to RHPs, deliver FREE-IA sessions to patients, and collect outcomes at three time points with low levels of attrition. Outcomes in all measures except disability were in a direction to suggest improvement at T1, T2, or both. Study numbers were small, there was no control group and regression to the mean was a possibility. However, outcomes were in the direction to cautiously suggest benefit, and there is evidence of promise of the intervention. A definitive RCT is the next step to test clinical and cost effectiveness of the intervention.
Disclosure
S. Bridgewater: None. J. Lomax: None. B. Abbott: None. J. Adams: None. A. Berry: None. S. Creanor: None. P. Ewings: None. S. Hewlett: None. L. McCracken: None. M. Ndosi: None. J. Thorn: None. M. Urban: None. E. Dures: None.
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Affiliation(s)
- Susan Bridgewater
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UNITED KINGDOM
- Academic Rheumatology, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UNITED KINGDOM
| | - Joe Lomax
- Faculty of Health, University of Plymouth, Plymouth, UNITED KINGDOM
| | - Bryan Abbott
- Academic Rheumatology, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UNITED KINGDOM
| | - Jo Adams
- Health Sciences, University of Southampton, Southampton, UNITED KINGDOM
| | - Alice Berry
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UNITED KINGDOM
- Academic Rheumatology, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UNITED KINGDOM
| | - Siobhan Creanor
- College of Medicine and Health, University of Exeter, Exeter, UNITED KINGDOM
| | - Paul Ewings
- Department of Research, Somerset NHS Foundation Trust, Taunton, UNITED KINGDOM
| | - Sarah Hewlett
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UNITED KINGDOM
| | - Lance McCracken
- Department of Psychology, Uppsala University, Uppsala, SWEDEN
| | - Mwidimi Ndosi
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UNITED KINGDOM
| | - Joanna Thorn
- Bristol Medical School, University of Bristol, Bristol, UNITED KINGDOM
| | - Marie Urban
- Academic Rheumatology, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UNITED KINGDOM
| | - Emma Dures
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UNITED KINGDOM
- Academic Rheumatology, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UNITED KINGDOM
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Al-Kaisy A, Royds J, Palmisani S, Pang D, Wesley S, Taylor RS, Cook A, Eldabe S, McCracken L, Duarte R, Fairbank J. Multicentre, double-blind, randomised, sham-controlled trial of 10 khz high-frequency spinal cord stimulation for chronic neuropathic low back pain (MODULATE-LBP): a trial protocol. Trials 2020; 21:111. [PMID: 31992344 PMCID: PMC6986091 DOI: 10.1186/s13063-019-3831-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 10/22/2019] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Chronic neuropathic low back pain (CNLBP) is a debilitating condition in which established medical treatments seldom alleviate symptoms. Evidence demonstrates that high-frequency 10 kHz spinal cord stimulation (SCS) reduces pain and improves health-related quality of life in patients with failed back surgery syndrome (FBSS), but evidence of this effect is limited in individuals with CNLBP who have not had surgery. The aim of this multicentre randomised trial is to assess the clinical and cost-effectiveness of 10 kHz SCS for this population. METHODS This is a multicentre, double-blind, randomised, sham-controlled trial with a parallel economic evaluation. A total of 96 patients with CNLBP who have not had spinal surgery will be implanted with an epidural lead and a sham lead outside the epidural space without a screening trial. Patients will be randomised 1:1 to 10 kHz SCS plus usual care (intervention group) or to sham 10 kHz SCS plus usual care (control group) after receiving the full implant. The SCS devices will be programmed identically using a cathodal cascade. Participants will use their handheld programmer to alter the intensity of the stimulation as per routine practice. The primary outcome will be a 7-day daily pain diary. Secondary outcomes include the Oswestry Disability Index, complications, EQ-5D-5 L, and health and social care costs. Outcomes will be assessed at baseline (pre-randomisation) and at 1 month, 3 months and 6 months after device activation. The primary analyses will compare primary and secondary outcomes between groups at 6 months, while adjusting for baseline outcome scores. Incremental cost per quality-adjusted life year (QALY) will be calculated at 6 months and over the lifetime of the patient. DISCUSSION The outcomes of this trial will inform clinical practice and healthcare policy on the role of high-frequency 10 kHz SCS for use in patients with CNLBP who have not had surgery. TRIAL REGISTRATION Clinicaltrials.gov, NCT03470766. Registered on 20 March 2018. DISCLAIMER The views expressed here are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. The NIHR had no role in the study design, writing of the manuscript or the decision to submit for publication. ROLES AND RESPONSIBILITIES AK, SP, DP, SW, RST, AC, SE, LM, RD and JF all contributed to the trial design and to securing trial funding. AK, JR, SP, DP, and SE are involved in the recruitment, the intervention and the follow-up. SW will perform data collection and analysis. RST will be responsible for the statistical analysis, and RD will be responsible for the health economic analysis. All authors read and approved the final manuscript.
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Affiliation(s)
- Adnan Al-Kaisy
- Pain Management & Neuromodulation Centre, St Thomas’ Hospital, Westminster Bridge Road, SE1 7EH London, UK
| | | | | | - David Pang
- Guys & St. Thomas NHS Foundation Trust, London, UK
| | | | - Rod S. Taylor
- Institute of Health and Well Being, University of Glasgow, Glasgow, UK
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Andrew Cook
- Wessex Institute, University of Southampton, Southampton, UK
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Sam Eldabe
- South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Lance McCracken
- Department of Psychology, Uppsala University, Uppsala, Sweden
| | - Rui Duarte
- Liverpool Reviews and Implementation Group, Health Services Research, University of Liverpool, Liverpool, UK
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Weeks KR, Gould RL, Mcdermott C, Lynch J, Goldstein LH, Graham CD, McCracken L, Serfaty M, Howard R, Al-Chalabi A, White D, Bradburn M, Young T, Cooper C, Shaw DPJ, Lawrence V. Needs and preferences for psychological interventions of people with motor neuron disease. Amyotroph Lateral Scler Frontotemporal Degener 2019; 20:521-531. [PMID: 31298054 DOI: 10.1080/21678421.2019.1621344] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Background: There is a lack of knowledge about what factors may impede or facilitate engagement in psychological interventions in people with motor neuron disease (pwMND) and how such interventions can be adapted to best meet the needs of this population. Objectives: To explore the needs and preferences of pwMND with respect to psychological interventions, and how best to adapt such interventions for pwMND. Methods: A series of semi-structured interviews (n = 22) and workshops (n = 3) were conducted with pwMND (n = 15), informal caregivers of pwMND (n = 10), and MND healthcare professionals (n = 12). These explored preferences and concerns that would need to be considered when delivering a psychological intervention for pwMND. Three areas were explored: (i) perceived factors that may hinder or facilitate pwMND engaging with psychological interventions; (ii) ways in which such interventions could be adapted to meet the individual needs of pwMND; and (iii) views regarding the main psychological issues that would need to be addressed. Workshops and interviews were audio recorded and transcribed and thematic analysis was used to inductively derive themes. Findings: Data could be classified within four overarching themes: unfamiliar territory; a series of losses; variability and difficulty meeting individual needs; and informal support. Conclusions: Flexibility, tailoring interventions to the individual needs of pwMND, and encouraging autonomy are key attributes for psychological interventions with pwMND. Psychological interventions such as Acceptance and Commitment Therapy (ACT) could be acceptable for pwMND if adapted to their specific needs.
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Affiliation(s)
- Kirsty R Weeks
- Faculty of Brain Sciences, Division of Psychiatry, University College London , London , UK
| | - Rebecca L Gould
- Faculty of Brain Sciences, Division of Psychiatry, University College London , London , UK
| | - Christopher Mcdermott
- Department of Neuroscience, Faculty of Medicine, Sheffield Institute for Translational Neuroscience (SITraN), Dentistry and Health, University of Sheffield , Sheffield , UK
| | - Jessica Lynch
- Faculty of Brain Sciences, Division of Psychiatry, University College London , London , UK
| | - Laura H Goldstein
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London , London , UK
| | | | - Lance McCracken
- Department of Psychology, Uppsala University , Uppsala , Sweden
| | - Marc Serfaty
- Faculty of Brain Sciences, Division of Psychiatry, University College London , London , UK.,Priory Hospital North London , London , UK
| | - Robert Howard
- Faculty of Brain Sciences, Division of Psychiatry, University College London , London , UK
| | - Ammar Al-Chalabi
- Department of Basic and Clinical Neuroscience, Maurice Wohl Clinical Neuroscience Institute, King's College London , London , UK.,Department of Neurology, King's College Hospital , London , UK
| | - David White
- Clinical Trials Research Unit, School of Health and Related Research (ScHARR), The University of Sheffield , Sheffield , UK , and
| | - Mike Bradburn
- Clinical Trials Research Unit, School of Health and Related Research (ScHARR), The University of Sheffield , Sheffield , UK , and
| | - Tracey Young
- Clinical Trials Research Unit, School of Health and Related Research (ScHARR), The University of Sheffield , Sheffield , UK , and
| | - Cindy Cooper
- Clinical Trials Research Unit, School of Health and Related Research (ScHARR), The University of Sheffield , Sheffield , UK , and
| | - Dame Pamela J Shaw
- Department of Neuroscience, Faculty of Medicine, Sheffield Institute for Translational Neuroscience (SITraN), Dentistry and Health, University of Sheffield , Sheffield , UK
| | - Vanessa Lawrence
- Health Services and Population Research, Institute of Psychiatry, Psychology and Neuroscience, King's College London , London , UK
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Critchley D, McCracken L, Wileman V, Galea Holmes M, Norton S, Godfrey E. Physiotherapy informed by Acceptance and Commitment Therapy (PACT) for people with chronic low back pain: a randomised controlled trial. Physiotherapy 2019. [DOI: 10.1016/j.physio.2018.11.279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Rose MR, Norton S, Vari C, Edwards V, McCracken L, Graham CD, Radunovic A, Chalder T. Acceptance and Commitment Therapy for Muscle Disease (ACTMus): protocol for a two-arm randomised controlled trial of a brief guided self-help ACT programme for improving quality of life in people with muscle diseases. BMJ Open 2018; 8:e022083. [PMID: 30287669 PMCID: PMC6194473 DOI: 10.1136/bmjopen-2018-022083] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 06/04/2018] [Accepted: 07/17/2018] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION In adults, muscle disease (MD) is often a chronic long-term condition with no definitive cure. It causes wasting and weakness of the muscles resulting in a progressive decline in mobility, alongside other symptoms, and is typically associated with reduced quality of life (QoL). Previous research suggests that a psychological intervention, and in particular Acceptance and Commitment Therapy (ACT), may help improve QoL in MD. ACT is a newer type of cognitive behavioural treatment that aims to improve QoL by virtue of improvement in a process called psychological flexibility. The primary aim of this randomised controlled trial (RCT) is to evaluate the efficacy of a guided self-help ACT programme for improving QoL in people with MD. Main secondary outcomes are mood, symptom impact, work and social adjustment and function at 9-week follow-up. METHODS AND ANALYSIS Acceptance and Commitment Therapy for Muscle Disease is an assessor-blind, multicentre, two-armed, parallel-group RCT to assess the efficacy of ACT plus standard medical care (SMC) compared with SMC alone. Individuals with a diagnosis of one of four specific MDs, with a duration of at least 6 months and with mild to moderate anxiety or depression (Hospital Anxiety and Depression Scale score ≥8) will be recruited from UK-based MD clinics and MD patient support organisations. Participants will be randomised to either ACT plus SMC or SMC alone by an independent randomisation service. Participants will be followed up at 3, 6 and 9 weeks. Analysis will be intention to treat, conducted by the trial statistician who will be blinded to treatment allocation. ETHICS AND DISSEMINATION The study has received full ethical approval. Study results will be disseminated via peer-reviewed publications, conference presentations and journal articles. Data obtained from the trial will enable clinicians and health service providers to make informed decisions regarding the efficacy of ACT for improving QoL for patients with MD. TRIAL REGISTRATION NUMBER NCT02810028. PROTOCOL VERSION V.11 (4 April 2017).
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Affiliation(s)
- Michael R Rose
- Department of Neurology, King's College Hospital, London, UK
| | - Sam Norton
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Chiara Vari
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Victoria Edwards
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Lance McCracken
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | | | | | - Trudie Chalder
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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10
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Casey MB, Smart K, Segurado R, Hearty C, Gopal H, Lowry D, Flanagan D, McCracken L, Doody C. Exercise combined with Acceptance and Commitment Therapy (ExACT) compared to a supervised exercise programme for adults with chronic pain: study protocol for a randomised controlled trial. Trials 2018; 19:194. [PMID: 29566744 PMCID: PMC5865382 DOI: 10.1186/s13063-018-2543-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 02/13/2018] [Indexed: 01/03/2023] Open
Abstract
Background Acceptance and Commitment Therapy (ACT) is a form of cognitive behavioural therapy, which may be beneficial for people with chronic pain. The approach aims to enhance daily functioning through increased psychological flexibility. Whilst the therapeutic model behind ACT appears well suited to chronic pain, there is a need for further research to test its effectiveness in clinical practice, particularly with regards to combining ACT with physical exercise. Methods/design This prospective, two-armed, parallel-group, single-centre randomised controlled trial (RCT) will assess the effectiveness of a combined Exercise and ACT programme, in comparison to supervised exercise for chronic pain. One hundred and sixty patients, aged 18 years and over, who have been diagnosed with a chronic pain condition by a physician will be recruited to the trial. Participants will be individually randomised to one of two 8-week, group interventions. The combined group will take part in weekly psychology sessions based on the ACT approach, in addition to supervised exercise classes led by a physiotherapist. The control group will attend weekly supervised exercise classes but will not take part in an ACT programme. The primary outcome will be pain interference at 12-week follow-up, measured using the Brief Pain Inventory-Interference Scale. Secondary outcomes will include self-reported pain severity, self-perception of change, patient satisfaction, quality of life, depression, anxiety and healthcare utilisation. Treatment process measures will include self-efficacy, pain catastrophising, fear avoidance, pain acceptance and committed action. Physical activity will be measured using Fitbit ZipTM activity trackers. Both groups will be followed up post intervention and again after 12 weeks. Estimates of treatment effects at follow-up will be based on an intention-to-treat framework, implemented using a linear mixed-effects model. Individual and focus group qualitative interviews will be undertaken with a purposeful sample of participants to explore patient experiences of both treatments. Discussion To our knowledge, this will be the first RCT to examine whether combining exercise with ACT produces greater benefit for patients with chronic pain, compared to a standalone supervised exercise programme. Trial registration www.ClinicalTrials.gov, ID: NCT03050528. Registered on 13 February 2017. Electronic supplementary material The online version of this article (10.1186/s13063-018-2543-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Máire-Bríd Casey
- School of Public Health, Physiotherapy and Sports Science, Health Sciences Building, University College Dublin, Belfield, Dublin 4, Ireland.
| | - Keith Smart
- Physiotherapy Department, St Vincents University Hospital, Elm Park, Dublin 4, Ireland
| | - Ricardo Segurado
- School of Public Health, Physiotherapy and Sports Science, Health Sciences Building, University College Dublin, Belfield, Dublin 4, Ireland
| | - Conor Hearty
- Department of Pain Medicine, Mater Misericordiae University Hospital, Eccles St, Dublin 7, Ireland
| | - Hari Gopal
- Department of Pain Medicine, Mater Misericordiae University Hospital, Eccles St, Dublin 7, Ireland
| | - Damien Lowry
- Psychology Department, Mater Misericordiae University Hospital, Eccles St, Dublin 7, Ireland
| | - Dearbhail Flanagan
- Physiotherapy Department, Mater Misericordiae University Hospital, Eccles St, Dublin 7, Ireland
| | - Lance McCracken
- Psychology Department, Institute of Psychiatry, Psychology and Neuroscience, Kings College London, 5th Floor Bermondsey Wing, Guy's Campus, London, SE1 9RT, United Kingdom
| | - Catherine Doody
- School of Public Health, Physiotherapy and Sports Science, Health Sciences Building, University College Dublin, Belfield, Dublin 4, Ireland
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Matcham F, Carroll A, Chung N, Crawford V, Galloway J, Hames A, Jackson K, Jacobson C, Manawadu D, McCracken L, Moxham J, Rayner L, Robson D, Simpson A, Wilson N, Hotopf M. Smoking and common mental disorders in patients with chronic conditions: An analysis of data collected via a web-based screening system. Gen Hosp Psychiatry 2017; 45:12-18. [PMID: 28274333 DOI: 10.1016/j.genhosppsych.2016.11.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 11/25/2016] [Accepted: 11/30/2016] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Smoking is the largest preventable cause of death and disability in the UK and remains pervasive in people with mental disorders and in general hospital patients. We aimed to quantify the prevalence of mental disorders and smoking, examining associations between mental disorders and smoking in patients with chronic physical conditions. METHOD Data were collected via routine screening systems implemented across two London NHS Foundation Trusts. The prevalence of mental disorder, current smoking, nicotine dependence and wanting help with quitting smoking were quantified, and the relationships between mental disorder and smoking were examined, adjusting for age, gender and physical illness, with multiple regression models. RESULTS A total of 7878 patients were screened; 23.2% screened positive for probable major depressive disorder, and 18.5% for probable generalised anxiety disorder. Overall, 31.4% and 29.2% of patients with probable major depressive disorder or generalised anxiety disorder respectively were current smokers. Probable major depression and generalised anxiety disorder were associated with 93% and 44% increased odds of being a current smoker respectively. Patients with depressive disorder also reported higher levels of nicotine dependence, and the presence of common mental disorder was not associated with odds of wanting help with quitting smoking. CONCLUSION Common mental disorder in patients with chronic physical health conditions is a risk factor for markedly increased smoking prevalence and nicotine dependence. A general hospital encounter represents an opportunity to help patients who may benefit from such interventions.
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Affiliation(s)
- Faith Matcham
- Department of Psychological Medicine, Institute of Psychology, Psychiatry and Neuroscience, King's College London, United Kingdom; NIHR Biomedical Research Centre for Mental Health at the South London and Maudsley NHS Foundation Trust, King's College London, United Kingdom.
| | - Amy Carroll
- Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - Natali Chung
- Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - Victoria Crawford
- King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - James Galloway
- King's College Hospital NHS Foundation Trust, London, United Kingdom; Department of Academic Rheumatology, King's College London, United Kingdom
| | - Anna Hames
- King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Karina Jackson
- St. John's Institute of Dermatology, Guy's and St. Thomas' NHS Foundation Trust, United Kingdom
| | - Clare Jacobson
- Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - Dulka Manawadu
- King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Lance McCracken
- Health Psychology Section, Psychology Department, Institute of Psychology, Psychiatry and Neuroscience, King's College London, United Kingdom
| | - John Moxham
- Department of Asthma, Allergy and Respiratory Science, King's College London, United Kingdom
| | - Lauren Rayner
- Department of Psychological Medicine, Institute of Psychology, Psychiatry and Neuroscience, King's College London, United Kingdom; NIHR Biomedical Research Centre for Mental Health at the South London and Maudsley NHS Foundation Trust, King's College London, United Kingdom
| | - Deborah Robson
- National Addiction Centre, Addictions Department, King's College London, United Kingdom
| | - Anna Simpson
- Department of Psychological Medicine, Institute of Psychology, Psychiatry and Neuroscience, King's College London, United Kingdom; NIHR Biomedical Research Centre for Mental Health at the South London and Maudsley NHS Foundation Trust, King's College London, United Kingdom
| | - Nicky Wilson
- King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Matthew Hotopf
- Department of Psychological Medicine, Institute of Psychology, Psychiatry and Neuroscience, King's College London, United Kingdom; NIHR Biomedical Research Centre for Mental Health at the South London and Maudsley NHS Foundation Trust, King's College London, United Kingdom
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12
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Bogosian A, Hurt CS, Vasconcelos E Sa D, Hindle JV, McCracken L, Cubi-Molla P. Distant delivery of a mindfulness-based intervention for people with Parkinson's disease: the study protocol of a randomised pilot trial. Pilot Feasibility Stud 2017; 3:4. [PMID: 28116120 PMCID: PMC5244573 DOI: 10.1186/s40814-016-0117-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 12/12/2016] [Indexed: 01/19/2023] Open
Abstract
Background Psychological difficulties, especially depression and anxiety, are the most prevalent non-motor symptoms in Parkinson’s disease. Pharmacological treatments for these conditions appear relatively ineffective in Parkinson’s disease. Mindfulness courses are increasingly popular and recognised as effective for managing emotional states, and there is growing evidence for the effectiveness of mindfulness courses for people with long-term medical conditions. With this exploratory pilot trial, we want to assess the feasibility of the procedures and processes, including recruitment, most appropriate outcome measure(s), acceptability of type and number of measures, potential nocebo effects, and potential effectiveness and cost-effectiveness of a specially adapted distance-delivered mindfulness-based intervention in people affected by Parkinson’s disease. Methods/Design This is a pilot two-arm randomised parallel group controlled trial. Sixty participants who meet eligibility criteria will be randomly assigned either to an 8-week mindfulness-based intervention group or a wait-list control group. The mindfulness intervention will include 1-h weekly sessions delivered by a health psychologist trained to facilitate mindfulness courses. Participants in both groups will complete standardised questionnaires assessing anxiety, depression, pain, insomnia, fatigue, and daily activities at four time points (baseline, 4, 8, and 20 weeks). The analysis will also consider potential mechanisms of change, such as acceptance, self-compassion, and tolerance of uncertainty, as well as health economic outcomes. Participants’ experiences of the mindfulness interventions will be explored via in-depth interviews. Discussion A mindfulness-based intervention for people with Parkinson’s delivered remotely, through Skype group videoconferences, may represent a viable, more accessible, intervention for people with mobility limitations and people who live in rural areas. The trial will provide important information about the feasibility, potential efficacy and cost-effectiveness, and acceptability of the intervention as well as mechanisms of psychosocial adjustment. The results of this pilot trial will help us design a phase III trial to assess efficacy of an online mindfulness-based intervention in Parkinson’s disease and evaluate significance. Trial registration ClinicalTrials.gov, NCT02683330
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Affiliation(s)
- A Bogosian
- Division of Health Services Research & Management, School of Health Sciences, City, University of London, EC1V 0HB London, UK
| | - C S Hurt
- Division of Health Services Research & Management, School of Health Sciences, City, University of London, EC1V 0HB London, UK
| | - D Vasconcelos E Sa
- Division of Health Services Research & Management, School of Health Sciences, City, University of London, EC1V 0HB London, UK
| | - J V Hindle
- School of Psychology, Bangor University, Bangor, UK
| | - L McCracken
- Health Psychology, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
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Critchley D, Holmes MG, Wileman V, McCracken L, Godfrey E. “A light bulb moment!” Physiotherapists’ experiences of delivering Physiotherapy informed by Acceptance and Commitment Therapy (PACT). Physiotherapy 2016. [DOI: 10.1016/j.physio.2016.10.285] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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14
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Godfrey E, Galea Holmes M, Wileman V, McCracken L, Norton S, Moss-Morris R, Pallet J, Sanders D, Barcellona M, Critchley D. Physiotherapy informed by Acceptance and Commitment Therapy (PACT): protocol for a randomised controlled trial of PACT versus usual physiotherapy care for adults with chronic low back pain. BMJ Open 2016; 6:e011548. [PMID: 27267109 PMCID: PMC4908884 DOI: 10.1136/bmjopen-2016-011548] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
INTRODUCTION Chronic low back pain (CLBP) is a common condition and source of significant suffering, disability and healthcare costs. Current physiotherapy treatment is moderately effective. Combining theory-based psychological methods with physiotherapy could improve outcomes for people with CLBP. The primary aim of this randomised controlled trial (RCT) is to evaluate the efficacy of Physiotherapy informed by Acceptance and Commitment Therapy (PACT) on functioning in patients with CLBP. METHODS AND ANALYSIS The PACT trial is a two-armed, parallel-group, multicentre RCT to assess the efficacy of PACT in comparison with usual physiotherapy care (UC). 240 patients referred to physiotherapy with CLBP will be recruited from three National Health Service (NHS) hospitals trusts. Inclusion criteria are: age ≥18 years, CLBP ≥12-week duration, scoring ≥3 points on the Roland-Morris Disability Questionnaire (RMDQ) and adequate understanding of spoken and written English to participate. Patients will be randomised to PACT or UC (120 per arm stratified by centre) by an independent randomisation service and followed up at 3 and 12 months post randomisation. The sample size of 240 will provide adequate power to detect a standardised mean difference of 0.40 in the primary outcome (RMDQ; 5% significance, 80% power) assuming attrition of 20%. Analysis will be by intention to treat conducted by the trial statistician, blind to treatment group, following a prespecified analysis plan. Estimates of treatment effect at the follow-up assessments will use an intention-to-treat framework, implemented using a linear mixed-effects model. ETHICS AND DISSEMINATION This trial has full ethical approval (14/SC/0277). It will be disseminated via peer-reviewed publications and conference presentations. The results will enable clinicians, patients and health service managers to make informed decisions regarding the efficacy of PACT for patients with CLBP. TRIAL REGISTRATION NUMBER ISRCTN95392287; Pre-results.
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Affiliation(s)
- Emma Godfrey
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Melissa Galea Holmes
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Vari Wileman
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Lance McCracken
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Sam Norton
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Rona Moss-Morris
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - John Pallet
- Faculty of Life Sciences and Medicine, Division of Health and Social Care Research, Department of Physiotherapy, King's College London, London, UK
| | - Duncan Sanders
- Pain Management Research Institute, Sydney Medical School—Northern, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | | | - Duncan Critchley
- Faculty of Life Sciences and Medicine, Division of Health and Social Care Research, Department of Physiotherapy, King's College London, London, UK
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Wong WS, McCracken L, Wong S, Chen PP, Chow YF, Fielding R. The Chinese version of the 8-item Committed Action Questionnaire (ChCAQ-8): A preliminary analysis of the factorial and criterion validity. Psychol Assess 2015. [PMID: 26214015 DOI: 10.1037/pas0000187] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Committed action is a key component of the psychological flexibility model that recently has been applied in chronic pain settings. Developed within the Western context, the 8-item Committed Action Questionnaire (CAQ-8) demonstrated good psychometric properties. This study aimed to translate the original English version of the CAQ-8 into Chinese (ChCAQ-8) and to assess its reliability, factor structure and concurrent criterion validity. A total of 210 Chinese patients with chronic pain completed the ChCAQ-8, the Chronic Pain Grade, the Pain Catastrophizing Scale, and the depression subscale of the Hospital Anxiety and Depression Scale. Results of confirmatory factor analysis showed both the 2-factor correlated (CFI = .99) and hierarchical (CFI = .98) models met the minimum acceptable fit criterion. The 2 subscales and the entire scale of ChCAQ-8 demonstrated good internal consistency (Cronbach's αs ranging .70-.86). The ChCAQ-8 negative subscale score was significantly correlated with pain intensity, disability, pain catastrophizing, and depression in the expected direction. The ChCAQ-8 positive subscale was significantly correlated with pain castastrophizing and depression. Results of multivariate regression modeling showed the ChCAQ-8 negative subscale predicted depression (std β = .19, p < .01) and disability (std β = .14, p < .05), after adjusting for pain intensity, pain duration and pain catastrophizing. Our findings offer preliminary data for the reliability, factorial and concurrent criterion validity of the ChCAQ-8 in the Chinese population. (PsycINFO Database Record
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Affiliation(s)
- Wing-Sze Wong
- Department of Psychological Studies, The Hong Kong Institute of Education
| | - Lance McCracken
- Health Psychology Section, Department of Psychology, Institute of Psychiatry, King's College London
| | - Steven Wong
- Department of Anesthesiology and Operating Services, Queen Elizabeth Hospital
| | - Phoon-Ping Chen
- Department of Anesthesiology and Operating Services, Alice Ho Miu Ling Nethersole Hospital
| | - Yu-Fat Chow
- Department of Anesthesiology and Operating Services, Queen Elizabeth Hospital
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16
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Rovner G, Årestedt K, Gerdle B, Börsbo B, McCracken L. Psychometric properties of the 8-item Chronic Pain Acceptance Questionnaire (CPAQ-8) in a Swedish Chronic pain cohort. J Rehabil Med 2014; 46:73-80. [DOI: 10.2340/16501977-1227] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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17
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Pincus T, Anwar S, McCracken L, McGregor A, Graham L, Collinson M, Farrin AJ. Testing the credibility, feasibility and acceptability of an optimised behavioural intervention (OBI) for avoidant chronic low back pain patients: protocol for a randomised feasibility study. Trials 2013; 14:172. [PMID: 23764140 PMCID: PMC3691616 DOI: 10.1186/1745-6215-14-172] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2013] [Accepted: 05/16/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chronic back pain continues to be a costly and prevalent condition. The latest NICE guidelines issued in 2009 state that for patients with persistent back pain (of between six weeks and twelve months duration), who are highly distressed and/or disabled and for whom exercise, manual therapy and acupuncture has not been beneficial, the evidence supports a combination of around 100 hours of combined physical and psychological treatment. This is costly, and may prove unacceptable to many patients. A key recommendation of these guidelines was for further randomised controlled trials (RCTs) of psychological treatment and to target treatment to specific sub-groups of patients. Recent trials that have included psychological interventions have shown only moderate improvement at best, and results are not maintained long term. There is therefore a need to test theoretically driven interventions that focus on specific high-risk sub-groups, in which the intervention is delivered at full integrity against a credible control. METHODS/DESIGN A feasibility study of a pragmatic randomised controlled trial comparing psychologist-delivered Contextual Cognitive Behavioural Therapy (CCBT) against Treatment As Usual (TAU) physiotherapy delivered by physiotherapists for the treatment of chronic lower back pain in 'avoidant' patients. Ninety-two patients referred for physiotherapy will be recruited and randomised on a 1:1 basis to receive CCBT or TAU. Treatment groups will be balanced by centre and pain interference score. Primary outcomes include assessing the credibility and acceptability of the intervention, and to demonstrate proof of principle through a greater change in pain acceptance in the CCBT arm, measured by the Acceptance and Action -II and the Chronic Pain Acceptance questionnaires. In addition, the feasibility of carrying out a full trial will be explored with reference to recruitment and follow-up rates including the assessment of the burden of outcome measure completion. Secondary patient outcomes include disability, pain, fear of movement, mood, quality of life, and global recovery. Outcomes are measured at three and six months post-randomisation. DISCUSSION This paper details the rationale, design, therapist training system and recruitment methods to be used in a feasibility study which will inform the design and efficient implementation of a future definitive RCT. TRIAL REGISTRATION ISRCTN43733490.
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Affiliation(s)
- Tamar Pincus
- Department of Psychology, University of London, Royal Holloway, Egham, Surrey TW20 0EX, UK
| | - Shamaila Anwar
- Clinical Trials Research Unit, University of Leeds, Leeds, LS2 9JT, UK
| | - Lance McCracken
- Health Psychology Section, Psychology Department, King’s College, 5th Floor Bermondsey Wing Guy’s Campus, London SE1 9RT, UK
| | - Alison McGregor
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Charing Cross Hospital, London W6 8RF, UK
| | - Liz Graham
- Clinical Trials Research Unit, University of Leeds, Leeds, LS2 9JT, UK
| | | | - Amanda J Farrin
- Clinical Trials Research Unit, University of Leeds, Leeds, LS2 9JT, UK
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Titulaer M, McCracken L, Gabilondo Cuellar I, Martinez-Hernandez E, Graus F, Balice-Gordon R, Dalmau J. Clinical Features, Treatment, and Outcome of 500 Patients with Anti-NMDA Receptor Encephalitis (PL01.001). Neurology 2012. [DOI: 10.1212/wnl.78.1_meetingabstracts.pl01.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Rosser BA, McCullagh P, Davies R, Mountain GA, McCracken L, Eccleston C. Technology-Mediated Therapy for Chronic Pain Management: The Challenges of Adapting Behavior Change Interventions for Delivery with Pervasive Communication Technology. Telemed J E Health 2011; 17:211-6. [DOI: 10.1089/tmj.2010.0136] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Paul McCullagh
- School of Computing and Mathematics, Computer Science Research Institute, The University of Ulster, Belfast, United Kingdom
| | - Richard Davies
- School of Computing and Mathematics, Computer Science Research Institute, The University of Ulster, Belfast, United Kingdom
| | - Gail A. Mountain
- The University of Sheffield, Regent Court, Sheffield, United Kingdom
| | - Lance McCracken
- Centre for Pain Research, The University of Bath, Bath, United Kingdom
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Huang Y, Zheng H, Nugent C, McCullagh P, Black N, Vowles KE, McCracken L. Feature selection and classification in supporting report-based self-management for people with chronic pain. ACTA ACUST UNITED AC 2010; 15:54-61. [PMID: 21075734 DOI: 10.1109/titb.2010.2091510] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Chronic pain is a common long-term condition that affects a person's physical and emotional functioning. Currently, the integrated biopsychosocial approach is the mainstay treatment for people with chronic pain. Self-reporting (the use of questionnaires) is one of the most common methods to evaluate treatment outcome. The questionnaires can consist of more than 300 questions, which is tedious for people to complete at home. This paper presents a machine learning approach to analyze self-reporting data collected from the integrated biopsychosocial treatment, in order to identify an optimal set of features for supporting self-management. In addition, a classification model is proposed to differentiate the treatment stages. Four different feature selection methods were applied to rank the questions. In addition, four supervised learning classifiers were used to investigate the relationships between the numbers of questions and classification performance. There were no significant differences between the feature ranking methods for each classifier in overall classification accuracy or AUC ( p > 0.05); however, there were significant differences between the classifiers for each ranking method ( p < 0.001). The results showed the multilayer perceptron classifier had the best classification performance on an optimized subset of questions, which consisted of ten questions. Its overall classification accuracy and AUC were 100% and 1, respectively.
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Affiliation(s)
- Yan Huang
- Computer Science Research Institute, School of Computing and Mathematics, University of Ulster, Jordanstown, UK
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21
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Vowles K, McCracken L, Zhao-O'Brien J. Acceptance and values-based action in chronic pain: an analysis of treatment outcomes and processes three years after treatment completion. The Journal of Pain 2010. [DOI: 10.1016/j.jpain.2010.01.228] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Kittiboonyakun P, Smith A, Eccleston C, McCracken L. Pattern and appropriateness of analgesic and adjuvant prescription in chronic non-malignant pain patients. International Journal of Pharmacy Practice 2010. [DOI: 10.1211/096176705777341217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Affiliation(s)
- P Kittiboonyakun
- Department of Pharmacy and Pharmacology, University of Bath, Bath, UK
| | - A Smith
- Department of Pharmacy and Pharmacology, University of Bath, Bath, UK
| | - C Eccleston
- Pain Management Unit, University of Bath and The Royal National Hospital for Rheumatic Diseases NHS Trust, Bath, UK
| | - L McCracken
- Pain Management Unit, University of Bath and The Royal National Hospital for Rheumatic Diseases NHS Trust, Bath, UK
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Roelofs J, McCracken L, Peters ML, Crombez G, van Breukelen G, Vlaeyen JW. Psychometric Evaluation of the Pain Anxiety Symptoms Scale (PASS) in Chronic Pain Patients. J Behav Med 2004; 27:167-83. [PMID: 15171105 DOI: 10.1023/b:jobm.0000019850.51400.a6] [Citation(s) in RCA: 135] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
This study examined psychometric properties of the Pain Anxiety Symptoms Scale (PASS), a measure of pain-related fear. A recently developed shortened version of the PASS, the PASS-20, was also investigated. Previously reported factor structures of the PASS were tested by means of confirmatory factor analysis. Results indicated that all models fitted adequately but that a five-factor solution fitted slightly better compared to the other models tested. The four-factor solution of the PASS-20 was tested by means of confirmatory factor analysis and results indicated adequate fit. Moreover, the four-factor solution of the PASS-20 was invariant among fibromyalgia and low-back pain patients. Convergent validity of the original PASS and the PASS-20 was good and internal consistency reliability adequate to excellent. The suitability of the original PASS and the PASS-20 are discussed and directions for future research are provided.
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Affiliation(s)
- Jeffrey Roelofs
- Department of Medical, Clinical and Experimental Psychology, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands.
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McCracken L. Cruci/section: my baby was cut out with a knife. Midwifery Today Int Midwife 2003:39-40. [PMID: 12596408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
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Roelofs J, Peters ML, McCracken L, Vlaeyen JWS. The pain vigilance and awareness questionnaire (PVAQ): further psychometric evaluation in fibromyalgia and other chronic pain syndromes. Pain 2003; 101:299-306. [PMID: 12583873 DOI: 10.1016/s0304-3959(02)00338-x] [Citation(s) in RCA: 214] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
In chronic pain patients, preoccupation with or attention to pain is associated with pain-related fear and perceived pain severity. The current study investigated psychometric properties of the pain vigilance and awareness questionnaire (PVAQ). An exploratory factor analysis on Dutch fibromyalgia patients indicated that a two-factor solution was most suitable. The first factor could be referred to as attention to pain and the second factor was interpreted as attention to changes in pain. A confirmatory factor analysis, testing three different factor structures in two independent samples (Dutch fibromyalgia patients and American pain patients with various diagnoses) showed that the goodness-of-fit indicators for all models were satisfactory. The existence of the previously reported intrusion subscale of the PVAQ as a unique construct within the PVAQ was discussed. This subscale should be further extended by non-reverse-keyed items. With regard to the convergent validity, the PVAQ was highly correlated with related constructs such as the pain catastrophizing scale (PCS), pain anxiety symptoms scale (PASS), and Tampa scale of kinesiophobia (TSK). The attention to pain subscale was significantly stronger associated with these pain-related measures than the attention to changes in pain subscale, indicating that attention to changes in pain is a distinctive construct. The uniqueness of the attention to changes in pain subscale was also supported by an exploratory factor analysis on all items of the PVAQ, PCS, PASS, and TSK which showed that all items from that scale loaded on one separate factor. Overall, the PVAQ showed good internal consistency. Implications for future research and treatment interventions are discussed.
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Affiliation(s)
- Jeffrey Roelofs
- Department of Medical, Clinical and Experimental Psychology, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands Pain Management Unit, Royal National Hospital for Rheumatic Disease and University of Bath, Bath, UK
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Risdon A, Eccleston C, Crombez G, McCracken L. How can we learn to live with pain? A Q-methodological analysis of the diverse understandings of acceptance of chronic pain. Soc Sci Med 2003; 56:375-86. [PMID: 12473322 DOI: 10.1016/s0277-9536(02)00043-6] [Citation(s) in RCA: 149] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
An analysis is reported of the variety of understandings available in British culture to understand acceptance of chronic pain. Q-factor analysis is used within a critical framework as Q-methodology. Thirty participants completed the procedure. Eight factors or accounts of accepting chronic pain were derived. These are reported as taking control, living day to day, acknowledging limitations, empowerment, accepting loss of self, more to life than pain, don't fight battles that cannot be won, and spiritual strength. Common features of accepting chronic pain are (1) the acknowledgement that a cure for pain is unlikely, (2) a shift of focus away from pain to non-pain aspects of life, and (3) a resistance to any suggestion that pain is a sign of personal weakness. Where accounts of chronic pain differ is in the extent to which acceptance of pain means a change in core aspects of self. Implications of this study for the study of chronic pain are discussed. In particular, how identity is managed in the context of threatening chronic pain is suggested as a fruitful area of future investigation.
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Affiliation(s)
- Andrea Risdon
- Pain Management Unit, University of Bath, 3 East, Bath BA2 7AY, UK
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McCracken L. Issue 57: Cesarean prevention/VBAC. Midwifery Today Int Midwife 2002:4. [PMID: 12154719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
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Wetzel FT, McCracken L, Robbins RA, Lahey DM, Carnegie M, Phillips FM. Temporal stability of the Minnesota Multiphasic Personality Inventory (MMPI) in patients undergoing lumbar fusion: a poor predictor of surgical outcome. Am J Orthop (Belle Mead NJ) 2001; 30:469-74. [PMID: 11411873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
Abstract
In this prospective study, the Minnesota Multiphasic Personality Inventory (MMPI) was administered to patients before and after lumbar spines fusion to investigate the stability of MMPI scores after surgical intervention and to attempt to correlate MMPI scale scores with outcome data. Sixty-eight patients were included. Testing was performed before surgery and at a mean of 1.5 years after surgery. Clinical outcome ratings were assigned by using criteria of pain relief and analgesic use. In addition, demographic variables known to affect outcome were analyzed. Sixty percent of the patients had a successful clinical outcome. Positive outcome correlated with the demographic factors of occupation (homemaker) and solid fusion. MMPI scales were stable across time, with no difference between groups. Independent t tests were used to study preoperative MMPI scores with respect to clinical outcome. Unsatisfactory outcomes were associated with higher scores on scales 1, 3, and 10 before surgery. Postoperative testing revealed significant outcome correlations--higher scores on scales 1, 2, 3, 5, 7, and 8 associated with an unsatisfactory outcome. However, discriminant function analysis of preoperative MMPI data was able to classify outcomes correctly in only 58.8% of the cases. The utility of the MMPI as a predictor of outcome after surgical intervention is quite limited. Use of group data and testing before and after surgery does not appear to influence this conclusion. Although the scores as a group were stable across time, the amount of variance in outcome that could not be accounted for by using MMPI scales as predictors was unacceptably large.
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Affiliation(s)
- F T Wetzel
- Section of Orthopaedic Surgery and Rehabilitation, University of Chicago Spine Center, Illinois, USA
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McCracken L. Birthing free at the edge of a new millennium. Midwifery Today Int Midwife 2001:40. [PMID: 11189623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
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McCracken L. The forensic ABCs of trauma care. Can Nurse 2001; 97:30-3. [PMID: 11865731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Affiliation(s)
- L McCracken
- Emergency Department, Foothills Medical Centre, Calgary, Alberta
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McCracken L. Intuitive unassisted homebirth: this one's for the babies. Midwifery Today Int Midwife 2000:34-5. [PMID: 11189564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
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McCracken L. A declaration of the rights of childbearing women. Midwifery Today Int Midwife 1999:39. [PMID: 10478051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
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Abstract
This study examines the relationship between a trauma history and emotional functioning in response to a chronic pain condition. We broadened the traditional study of trauma in chronic pain from sexual and physical abuse to include a variety of traumatic events and experiences that occurred not only during childhood, but during adulthood as well. Seventy-three (51% female, 60% lower back) chronic pain patients were administered the Trauma History Questionnaire (Green, B.L., Trauma History Questionnaire. In B.H. Stamm (Eds.), Measurement of Stress, Trauma and Adaptation, Sidran, Lutherville, MD, 1996, pp. 366-369), the Multidimensional Pain Inventory (Kerns, R.D., Turk, D.C. and Rudy, T.E., The West Haven-Yale Multidimensional Pain Inventory (WHYMPI), Pain, 23 (1985) 345-356), The Beck Depression Inventory (Beck, A.T., Ward, C.H., Mendelson, M., Mock, J. and Erbaugh, J., An inventory for measuring depression, Arch. Gen Psychiatry, 4 (1961) 561-571), and the Pain Anxiety Symptoms Scale (McCracken, L.M., Zayfert, C., Gross, R.T. The Pain Anxiety Symptoms Scale: development and validation of a scale to measure fear of pain, Pain, 50 (1992) 67-73) prior to starting a multidisciplinary pain program. We hypothesized that high levels of emotional distress and anxiety would differentiate patients with a substantial history of trauma from those without, while levels of pain severity and disability would not. A MANOVA revealed a significant Trauma Group (low vs. high) by Gender interaction for the dependent variables, which included both measures of emotional distress and pain severity and disability. Univariate tests showed that the interaction was significant only for emotional distress variables and not for pain severity and disability. Further, the multivariate effect of Trauma Group and the univariate effects for emotional distress variables were significant only among men. Results indicate that a substantial history of trauma may detrimentally impact a chronic pain patient's ability to manage their pain effectively, particularly among men.
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Affiliation(s)
- Ilyse L Spertus
- Department of Psychology, Finch University of Health Sciences, The Chicago Medical School, 3333 Green Bay Road, North Chicago, IL 60064, USA Pain and Rehabilitation Clinic of Chicago, 640 N. LaSalle, Chicago, IL, USA Department of Psychiatry, University of Chicago, 5841 S. Maryland Avenue (MC 3077), Chicago, IL 60637, USA
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Abstract
A total of 167 Department of Veterans Affairs medical centers responded to a survey that sought information on suicidal behavior during a one-year period among patients in inpatient or outpatient treatment. Of 248 completed suicides during the period, about 60 percent occurred among patients in outpatient mental health treatment. The incidence of anxiety disorder diagnoses (17.7 percent), particularly posttraumatic stress disorder, among patients who completed suicide was much higher than that reported for persons who completed suicide in the general population. Many patients with psychiatric diagnoses who completed suicide had comorbid substance abuse diagnoses.
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Affiliation(s)
- L Lehmann
- Mental Health and Behavioral Sciences Service, Department of Veterans Affairs, Washington, DC 20420, USA
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Fox RA, McCracken L. Aging and the influence of contextual contrast on vowel identification. Percept Mot Skills 1989. [PMID: 2622730 DOI: 10.2466/pms.1989.69.3f.1163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
This study examines possible differences between young and older adult listeners in the effect of contextual contrast on vowel identification using a vowel anchoring procedure. All listeners identified a 7-step [i]-[I] continuum under both an equiprobable control condition and an anchoring condition (in which one endpoint stimulus occurred four times more often than any other single stimulus token). Phoneme boundaries in the anchoring condition shifted toward the anchor endpoint, as expected, for both groups, but there was a significant effect of age when [i] served as the anchor. Evidence of an increase in response bias for older adult listeners was also found.
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Affiliation(s)
- R A Fox
- Division of Speech and Hearing Science, Ohio State University, Columbus, 43210-1372
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Fox RA, McCracken L. Aging and the Influence of Contextual Contrast on Vowel Identification. Percept Mot Skills 1989; 69:1163-70. [PMID: 2622730 DOI: 10.1177/00315125890693-218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study examines possible differences between young and older adult listeners in the effect of contextual contrast on vowel identification using a vowel anchoring procedure. All listeners identified a 7-step [i]—[I] continuum under both an equiprobable control condition and an anchoring condition (in which one end-point stimulus occurred four times more often than any other single stimulus token). Phoneme boundaries in the anchoring condition shifted toward the anchor endpoint, as expected, for both groups, but there was a significant effect of age when [i] served as the anchor. Evidence of an increase in response bias for older adult listeners was also found.
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Affiliation(s)
- R A Fox
- Division of Speech and Hearing Science, Ohio State University, Columbus, 43210-1372
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Cella G, Cunningham T, Palla A, McCracken L, Godin PF, Tow DE, Sasahara AA. An improved method for the sterile preparation of indium-111-labeled platelets. J Nucl Med Allied Sci 1986; 30:129-32. [PMID: 3794815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Cella G, Colby SI, Taylor AD, McCracken L, Parisi AF, Sasahara AA. Platelet factor 4 (PF4) and heparin-released platelet factor 4 (HR-PF4) in patients with cardiovascular disorders. Thromb Res 1983; 29:499-509. [PMID: 6222505 DOI: 10.1016/0049-3848(83)90345-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The recent introduction of the determinations of platelet factor 4 (PF4) and beta-thromboglobulin (beta TG) by radioimmunoassay provided a new tool to obtain knowledge of in vivo platelet activation. We evaluated the plasma level of PF4 and beta TG in 14 normal subjects (mean PF4 7.7 ng/ml; beta TG 28.8 ng/ml), in 29 patients with chronic stable cardiovascular disorders (mean PF4 9.8 ng/ml; beta TG 32.6 ng/ml) and in 15 diabetics with vascular disease (mean PF4 14.5 ng/ml; beta TG 41.8 ng/ml). The great majority had normal values and no statistical differences were noted among the three groups (p greater than 0.05). Fifteen days of treatment with 150 mg daily of dipyridamole produced a significant reduction in the levels of both proteins (p less than 0.01), in contrast of the daily administration of 650 mg of aspirin, which failed to produce any significant change (p greater than 0.5). The patients and the normal subjects were also administered 3,000 USP units intravenously of porcine heparin. The values of the heparin released-platelet factor 4 (HR-PF4), evaluated 5 minutes after the injection, showed a good correlation between platelet concentration and HR-PF4 levels (z = 2.37, p less than 0.02) in the patients. The determination of standard residual following linear regression analysis of HR-PF4 indicated the presence of two distinct patient populations. One group, including the vast majority of patients, did not differ from the control (patients mean HR-PF4 111.1 ng/ml; controls: mean HF-PF4 136 ng/ml). The other group, with severe cardiovascular disease, but with normal levels of PF4 and beta TG in almost all patients and similar platelet concentrations, showed a significantly higher HR-PF4 (219 ng/ml). Neither aspirin nor dipyridamole had any effect on the level of HR-PF4. This HR-PF4 could represent a possible marker of the interaction of platelets with a seriously damaged atherosclerotic vessel wall.
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